Provider Demographics
NPI:1134193816
Name:ALTENBURG, ELLEN M (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:ALTENBURG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 S APOLLO BLVD STE 406
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3185
Mailing Address - Country:US
Mailing Address - Phone:321-727-2990
Mailing Address - Fax:321-724-0455
Practice Address - Street 1:6300 N WICKHAM RD STE 132B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2023
Practice Address - Country:US
Practice Address - Phone:321-425-6900
Practice Address - Fax:321-802-5599
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023468700Medicaid
F05182Medicare UPIN